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In breast cancer, cells in your breast begin growing abnormally often for unknown reasons. These cells divide more rapidly than healthy cells and may spread through your breast or into other parts of your body. The most common type of breast cancer begins in the ducts designed to carry milk after childbirth, but cancer may also occur in the small sacs that produce milk (lobules) or in other breast tissue.
Breast cancer is the disease many women fear most, though they’re far more likely to die of cardiovascular disease than they are of all forms of cancer combined. Still, breast cancer is second only to lung cancer as a cause of cancer deaths in American women. More than 200,000 American women are diagnosed annually with breast cancer. And nearly 40,000 American women die annually of breast cancer. Although rare, breast cancer can also occur in men.
Yet there’s more reason for optimism with regard to breast cancer than ever before. Great strides have been made in diagnosis and treatment in the last 25 years. In 1975 a diagnosis of breast cancer usually meant radical mastectomy removal of the entire breast along with underarm lymph nodes and skin and muscles underneath the breast. Today, radical mastectomy is rarely performed. Instead, there are more and better treatment options, and many women are candidates for breast-sparing operations, such as lumpectomy.
Emphasis is also being placed on early detection, lifestyle changes and therapies such as tamoxifen that may reduce the risk of breast cancer. In addition, a growing network of agencies and resources exist to help those who have just received a diagnosis, are facing treatment decisions or are living with breast cancer.
Knowing the signs and symptoms of breast cancer may help save your life. When the disease is discovered early, you have more treatment options and a better chance for long-term recovery. In fact, when breast cancer is diagnosed and treated in its early stages, the five-year survival rate is 95 percent.
Most breast lumps aren’t cancerous. Yet the most common sign of breast cancer for both men and women is a lump or thickening in the breast. Often, the lump is painless. Other signs of breast cancer include:
A number of factors other than breast cancer can cause your breasts to change in size or feel. In addition to the natural changes that occur during pregnancy and your menstrual cycle, other common noncancerous (benign) breast conditions include:
If you find a lump or other change in your breast and haven’t yet gone through menopause, you may want to wait through one menstrual cycle before seeing your doctor. If the change hasn’t gone away after a month, have it evaluated promptly.
Screening – looking for evidence of disease before symptoms appear is the key to finding breast cancer in its early, treatable stages. Depending on your age and risk factors, screening may include breast self-examination, examination by your nurse or doctor (clinical breast exam), mammograms (mammography) or other tests.
Breast self-examinationFor years, women have been advised to examine their breasts on a monthly basis starting around age 20. The hope was that by becoming proficient at breast self-examination and familiar with the usual appearance and feel of their breasts, women would be able to detect early signs of cancer.
But some studies have shown that teaching women to perform breast self-exams may not accomplish this goal. A large, randomized clinical study in Shanghai, China, for example, concluded that breast self-exams don’t actually reduce the number of deaths from breast cancer. In addition, the study found that women who perform regular breast self-exams may be more likely to undergo unnecessary biopsies after finding breast lumps. This was one of the primary reasons that in May 2003 the American Cancer Society changed its recommendations on breast self-examination, stating that the procedure should be considered an option, rather than a requirement, for most women.
The new guidelines emphasize breast health awareness instead of a strict series of monthly self-exams. Although the guidelines don’t say you shouldn’t perform the exams, the importance of self-exams has been replaced by a general need to become more familiar with your breasts. If you’d like to continue performing breast self-exams, ask your doctor to review your technique.
Clinical breast exam
Unless you have a family history of cancer or other factors that place you at high risk, the American Cancer Society recommends having clinical breast exams once every three years until age 40. After that, the American Cancer Society recommends having a yearly clinical exam.
During this exam, your doctor examines your breasts for lumps or other changes. He or she may be able to feel lumps you miss when you examine your own breasts and will also look for enlarged lymph nodes in your armpit (axilla).
A mammogram, which uses a series of X-rays to show images of your breast tissue, is currently the best imaging technique for detecting tumors before you or your doctor can feel them. For that reason, the American Cancer Society has long recommended screening mammography for all women over 40.
Yet mammograms aren’t perfect. About 10 percent to 15 percent of breast cancers sometimes even lumps you can feel don’t show up on X-rays (false-negative result). The rate is higher about 25 percent for women in their 40s. That’s because women of this age and younger tend to have denser breasts, making it more difficult to distinguish abnormal from normal tissue.
At other times, mammograms may indicate a problem when none exists (false-positive result). This can lead to unnecessary biopsies, fear and anxiety, as well as to increased health care costs. Even so, the consensus has been that if mammography saves lives, then all eligible women should be screened.
That assumption has been challenged in recent years especially by a 2001 analysis of several large, long-term studies that raised questions about the benefit of mammography screening for breast cancer. The report concluded that several prior studies didn’t clearly show that screening mammograms result in fewer deaths from breast cancer. This led to great confusion about mammography for both women and doctors.
But a study published in April 2003, in which researchers followed more than 200,000 Swedish women for 20 years, hopes to end the confusion. That study found that mammogram screening does indeed reduce breast cancer mortality for women between the ages of 40 and 69 by as much as 28 percent. What’s more, the study’s authors say that mammography screening along with improved treatments can halve the number of deaths from breast cancer.
In May 2003, the American Cancer Society issued updated guidelines on breast cancer screening, strongly reaffirming its recommendation that women 40 and older have annual mammograms. Additional American Cancer Society screening guidelines include the following:
During a mammogram, your breasts are compressed between plastic plates while a radiology technician takes the X-rays. The whole procedure should take less than 30 minutes. You may find mammography somewhat uncomfortable. If you have too much discomfort, inform the technician. If you have tender breasts, schedule your mammogram for a time after your menstrual period. Avoiding caffeine for two days before the test also helps reduce breast tenderness.
Also available at some mammography centers is a soft, single-use, foam pad that can be placed on the surface of the compression plates of the mammography machine, making the test kinder and gentler. The pad doesn’t interfere with the image quality of the mammogram.
If possible try to schedule your mammogram around the same time as your annual clinical exam. That way the radiologist can specifically look at any changes your doctor may discover.
Most importantly, don’t let a lack of health insurance keep you from having regular mammograms. Many state health departments and Planned Parenthood clinics offer low-cost or free screenings. So does the Encore Plus program available through many YWCAs.
Other screening tests
If you, your doctor or a mammogram detects a lump in your breast, you’ll likely have one or more diagnostic procedures to determine if the lump is cancerous, including:
Estrogen and progesterone receptor tests
If a biopsy reveals malignant cells, your doctor will recommend additional tests such as estrogen and progesterone receptors tests on the malignant cells. These tests help determine whether female hormones affect the way the cancer grows. If the cancer cells have receptors for estrogen or progesterone or both, your doctor may recommend treatment with a drug such as tamoxifen that prevents estrogen from binding to these sites.
Staging tests help determine the size and location of your cancer, and whether it has spread. They also help your doctor determine the best treatment for you. Cancer is staged using the numbers 0 through IV.
Stage 0 cancers are also called noninvasive or in situ (in one place) cancers. Although they don’t have the ability to spread to other parts of your body or invade normal breast tissue, it’s important to have them removed because they eventually can become invasive cancers. Finding and treating a cancerous lump at this stage offers the best chance for a full recovery.
Stage I to IV cancers are invasive tumors that have the ability to spread to other areas. A stage I cancer is small and well localized, and has a very successful treatment rate. But the higher the stage number, the lower the chances of cure. By stage IV, the cancer has spread beyond your breast to other organs, such as your bones, lungs or liver. Although it may not be possible to eliminate the cancer at this stage, its spread may be controlled with radiation, chemotherapy or both.
The discovery of BRCA1, BRCA2 and other genes that may significantly increase breast cancer risk has raised a number of emotional and legal questions about genetic testing. A simple blood test can help identify defective BRCA genes, but it’s only 85 percent accurate, and most experts believe that only those women at high risk of hereditary breast or ovarian cancers should be referred for testing. If you’re one of these women, it’s important to know that having a defective BRCA gene doesn’t mean you’ll get breast cancer. In addition, test results cannot determine how high your risk is, at what age you might develop cancer, how aggressively the cancer might progress or what your risk of death may be.
In general, testing is most beneficial if the results of the test will help you make a decision about how you might best reduce your chance of developing breast cancer. Options range from lifestyle changes, closer screening and therapy with medications such as tamoxifen to extreme measures such as preventive (prophylactic) bilateral mastectomy or removal of your ovaries (oophorectomy). These can be wrenching decisions for any woman to make. Be sure to thoroughly discuss all your options with a genetic counselor, who can explain the risks, benefits and limitations of genetic testing. It can also help to talk to other women who have had to make similar decisions.
A diagnosis of breast cancer is one of the most difficult experiences you can face. In addition to coping with a life-threatening illness, you must make complex decisions about treatment. Remember, in most cases no one right treatment exists for breast cancer. Instead, you’ll want to find the approach that’s best for you.
To do that, you’ll need to consider many different factors, including the type and stage of your cancer, your age, risk factors, where you are in your life, the size and shape of your breasts, and your feelings about your body.
Before making any decisions, learn as much as you can about the many treatment options that exist. Talk extensively with your health care team. Consider a second opinion from a breast specialist in a breast center or clinic. Don’t be afraid to ask questions. In addition, look for breast cancer books, Web sites and information available from organizations such as the American Cancer Society and the Susan G. Komen Breast Cancer Foundation. Talking to other women who have faced the same decision also may help. This may be the most important decision you ever make.
Treatments exist for every type and stage of breast cancer. Most women will have surgery and an additional (adjuvant) therapy such as radiation, chemotherapy or hormone therapy. And several experimental treatments are now offered on a limited basis or are being studied in clinical trials.
At one time, the only type of breast cancer surgery was radical mastectomy, which removed the entire breast, along with chest muscles beneath the breast and all the lymph nodes under the arm. Today, this operation is rarely performed. Instead, the majority of women are candidates for breast-saving operations, such as lumpectomy. Less radical mastectomies and mastectomy with reconstruction are also options.
Breast cancer operations include the following:
Most women who undergo mastectomy are able to choose whether to have breast reconstruction. This is a very personal decision, and there’s no right or wrong choice. You may find, however, that you have feelings you didn’t expect about your breasts. It’s important to understand these feelings before making any decision.
If you would like reconstruction but aren’t a candidate for the procedure, you’ll need to find a way to come to terms with your disappointment. It may be extremely helpful to talk to other women who have experienced the same situation.
If reconstruction is an option, your surgeon will refer you to a plastic surgeon. He or she can describe the procedures to you and show you photos of women who have had different types of reconstruction. Your options include reconstruction with a synthetic breast implant or reconstruction using your own tissue to rebuild your breast. These operations can be performed at the time of your mastectomy or at a later date.
Radiation therapy uses high-energy X-rays to kill cancer cells and shrink tumors. If you choose lumpectomy, or if a biopsy has confirmed that there are cancer cells in more than four lymph nodes in your armpit, your oncologist will likely recommend radiation to your chest wall after your mastectomy. Although the thought of radiation can be disturbing, it may help to know that it’s a more accurate and less aggressive treatment than it once was.
Radiation is usually started three to four weeks after surgery. You’ll typically receive treatment five days a week for six to seven weeks. The treatments are painless and are similar to getting an X-ray. Each takes about 30 minutes. The effects are cumulative, however, and you may become tired toward the end of the series. Your breast may be pink, puffy and somewhat tender, as if it had been sunburned.
More serious, long-term complications are rare but can sometimes occur. These include rib fractures, lung inflammation, injury to the heart, nerve damage and a change in the appearance and consistency of breast tissue. In extremely rare cases, a new tumor may result from radiation therapy.
Chemotherapy uses drugs to destroy cancer cells. Your doctor may recommend chemotherapy following surgery to kill any cancer cells that may have spread outside your breast. Treatment often involves receiving two or more drugs in different combinations. These may be administered intravenously, in pill form or both. You may have between four and eight treatments spread over three to six months.
In some cases, your doctor may suggest preoperative chemotherapy taking chemotherapy drugs to shrink a breast tumor before surgery. This may make it possible for you to have a lumpectomy rather than a mastectomy to remove the cancer, with the same survival rate as if you were to have chemotherapy after breast surgery.
No matter when it’s administered, chemotherapy can feel like another illness. The side effects may include hair loss, nausea, vomiting and fatigue. These occur because chemotherapy affects healthy cells especially fast-growing cells in your digestive tract, hair and bone marrow as well as cancerous ones. Not everyone has side effects, however, and there are now better ways to control them if you do.
Many new drugs can help prevent or greatly reduce nausea. Relaxation techniques, including guided imagery, meditation and deep breathing also may help. In addition, exercise has been shown to be effective in reducing fatigue caused by chemotherapy.
Hormone therapy is most often used to treat women with advanced (metastatic) breast cancer or as an adjuvant treatment a therapy that seeks to prevent a recurrence of cancer for women diagnosed with early-stage estrogen-receptor-positive cancer. Estrogen-receptor-positive cancer means that estrogen or progesterone might encourage the growth of breast cancer cells in your body. Normally, estrogen and progesterone bind to certain sites in your breast and in other parts of your body. But during this treatment, a hormonal medication binds to these sites instead and prevents estrogen from reaching them. This may help destroy cancer cells that have spread or reduce the chances that your cancer will recur.
Medications that reduce the effect of estrogen in your body include:
Sometimes called biological response modifier or immunotherapy, this treatment tries to stimulate your body’s immune system to fight cancer. Using substances produced by the body or similar substances made in a laboratory, biological therapy seeks to enhance your body’s natural defenses against specific diseases. Many of these therapies are experimental and available only in clinical trials. One medication, trastuzumab (Herceptin), is a monoclonal antibody a substance produced in a laboratory by mixing cells that’s available for treating certain advanced cases of breast cancer. Herceptin is effective against tumors that produce excess amounts of a protein called HER-2, which occurs in about 25 percent of breast cancers.
A number of new approaches to treating cancer are being studied. The emphasis is on methods that can successfully treat women or extend their survival with minimal side effects. Among these are drugs that block the biochemical switches that cause normal cells to turn cancerous. In addition, a procedure known as anti-angiogenesis which targets the blood vessels that supply nutrients to cancer cells is also being studied. And gene therapy is an area of ongoing research.
Of particular interest to both women and their doctors are methods of removing breast cancer without actually cutting into or removing the breast. Nonsurgical methods being studied include techniques that use heat or cold to kill cancer cells deep within the breast, leaving only minimal scars.
One of the most researched techniques, radiofrequency ablation, uses ultrasound to locate the tumor. Then a metal probe about the size of a toothpick is inserted into the tumor where it creates heat that destroys cancer cells. In early tests, the procedure has proved enormously successful. Still, only about 25 percent of women would be candidates for the procedure if it eventually were approved for widespread use.
Some of these new treatments are available through clinical trials the standard way new therapies are tested in people. If you have advanced breast cancer and are interested in participating in a clinical trial, talk to your doctor or contact the National Cancer Institute’s Information Service at 800-422-6237 for more information.
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